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Objective Common treatments for obstructive hydrocephalus caused by malignant midline intracranial tumors during the perioperative period include ventriculoperitoneal shunt (VPS) placement/endoscopic third ventriculostomy (ETV) and direct tumor resection, but which of these treatments is superior remains unclear. The purpose of this study is to explore the management of hydrocephalus during the perioperative period and subsequent outcomes. Methods Data from 372 patients with obstructive hydrocephalus due to malignant midline intracranial tumors under the age of 18 years referred to the Department of Pediatric Neurosurgery at Beijing Tiantan Hospital between January 2018 and September 2019 were collected. We also collected their clinical features and outcomes for further statistical analysis. Results A total of 372 pediatric patients were treated for obstructive hydrocephalus. In total, 215 patients underwent preoperative VPS placement; the effectiveness of preoperative VPS placement was 98.1% (211/215), and the mean duration of relapse was 63.5 ± 15.7 days. Forty children underwent ETV before tumor removal; the effectiveness of preoperative ETV was 90.0% (36/40), and the mean duration of relapse was 53.8 ± 44.9 days. A total of 117 patients underwent direct tumor resection after being diagnosed; the recurrence rate of hydrocephalus was 20.5% (24/117), and the mean duration of relapse was 125.0 ± 170.8 days. There was a significant difference between preoperative VPS placement followed by resection and postoperative VPS placement and preoperative ETV followed by resection and postoperative VPS placement (p = 0.013). Conclusion Malignant midline intracranial tumors in pediatric patients usually lead to obstructive hydrocephalus, and preoperative intervention for hydrocephalus (VPS or ETV) will improve patient outcomes. The optimal management strategy for obstructive hydrocephalus due to malignant midline intracranial tumors is preoperative VPS placement or ETV due to their low hydrocephalic recurrence rates and high effectiveness.